Provider Demographics
NPI:1083775878
Name:PUCKETT FAMILY EYE CARE, PLLC
Entity Type:Organization
Organization Name:PUCKETT FAMILY EYE CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:K
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:859-744-4429
Mailing Address - Street 1:1109 MCCANN DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1178
Mailing Address - Country:US
Mailing Address - Phone:859-744-4429
Mailing Address - Fax:859-744-3941
Practice Address - Street 1:1109 MCCANN DR
Practice Address - Street 2:SUITE 2
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1178
Practice Address - Country:US
Practice Address - Phone:859-744-4429
Practice Address - Fax:859-744-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1190DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty